CMS Issues 2009 Proposed Outpatient & ASC Rule

Cardiac Rhythm Management and Electrophysiology Reimbursement Update

Last updated: July 2008

On Thursday, July 3rd , 2008, the Centers for Medicare and Medicaid Services (CMS) released the proposed rates for the 2009 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) payments. Some of the changes that affect Cardiac Rhythm Management (CRM) and Electrophysiology (EP) procedures are detailed below. The comment period for the proposed rule ends on September 2, 2008. CMS will release the final rule on or about November 1, 2008 which will go into effect on January 1, 2009.

Base Payment Changes CRM services for 2009

The table below shows the proposed 2009 Ambulatory Payment Classification (APC) rates for ICD and pacemaker system implants compared to 2008 APC rates, and the base payment rates for CRM APCs. Note that LV lead payments are proposed to decrease by 47%. This is due to a calculation methodology applied by CMS. BSC plans to comment on this methodology and the impact it may have on this therapy. Payments for a CRT-D system implant in the outpatient setting may decrease by 9%, largely due to lower LV lead payment.

Generally, ASC rates are set at 65% of APC payments, therefore, ASC rates are proposed to receive similar increases and decreases in 2009. However, rates for CRM procedures are set at 85% to 95% of APC rates.

APC	Procedure	CY09* vs. CY08	Base APC Reimbursement**
0108	ICD System Implant	+4%	$26,722
0107	ICD/CRT-D PG Only	+1%	$21,487
0108 + 0418†	CRT-D System Implant + LV Lead	-9%	$31,043
0418	LV Lead Only	-47%	$8,643
0089	Pacemaker Single Chamber System	-3%	$7,528
0090	Pacemaker Single Chamber PG Only	-3%	$6,222
0655	Pacemaker Dual Chamber System	+4%	$9,284
0654	Pacemaker Dual Chamber PG Only	+2%	$7,109

The percent changes shown are base payments and will vary for individual hospitals.
** Final rates may vary due to geographic wage differences.
† 50% discount applied to 0418 due to "T" status: “Significant Procedure, Multiple Reduction Applies.” See Addendum D1 in OPPS regulation and notices.

Base Payment Changes for EP Procedures for 2009

The table below shows a sample of the final 2009 APC rates for EP procedures compared to 2008 APC rates, and the base payment rates for EP APCs.

APC	Procedure	CY09* vs. CY08	Base APC Reimbursement**
080	Diagnostic Cardiac Catheterization	+5%	$2,599
8000^	Cardiac Electrophysiologic Evaluation and Ablation Composite	+8%	$9,190
0084	Level I EP Procedures	+13%	$690
0085	Level II EP Procedures	+7%	$ 3,210
0086	Level III EP Procedures	+11%	$ 6,542

* The percent changes shown are base payments and will vary for individual hospitals.
** Final rates may vary due to geographic wage differences.
^ New Composite APC for EP Evaluation & Ablation performed on the same day. Generally, APCs 0084-0086 apply when services rendered do not qualify for APC 8000 (e.g., evaluation and ablation performed on different dates). APC 0087 is now included in the Composite APC and not paid separately.
^^ Payment for ICE will now be bundled into the primary APC.

OPPS Highlights

• CMS is proposing an overall, average increase of 3% for 2009 OPPS hospital payment rates.
• There will be no separate payments for Intracardiac Echodardiography (ICE) despite BSC-led efforts to reinstate distinct payment. CMS sees no basis for treating ICE differently from other intraoperative services.
• CMS is proposing to add four new measures of imaging efficiency to the seven existing quality measures in CY 2010 which would be required for hospitals to measure and submit to receive the full market basket update increase of 3.0%.

Additional Information

• Read Medicare's press release
• Read the full 2009 OPPS & ASC Proposed Rule

For questions related to the reimbursement of CRM products, call 1.800.CARDIAC (1.800.227.3422) and ask for the Reimbursement Call Center .

Disclaimer: The information provided in this document was obtained from third-party sources and is subject to change without notice as a result of changes in reimbursement laws, regulations, rules and policies. All content in this document is informational only, general in nature, and does not cover all situations or all payers' rules and policies. This content is not intended to instruct medical providers on how to use or bill for health care procedures, including new technologies outside of Medicare national guidelines. A determination of medical necessity is a prerequisite that Boston Scientific assumes will have been made prior to assigning codes or requesting payments. Medical providers should consult with appropriate payers, including Medicare fiscal intermediaries and carriers, for specific information on proper coding, billing, and payment levels for health care procedures.

This document represents no promise or guarantee by Boston Scientific concerning coverage, coding, billing, and payment levels. Boston Scientific specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on information in this document.

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